The incident at Lincoln Hills School for Boys and Copper Lake School for Girls generated only a cursory review and virtually no accountability at the time for inadequate training, according to hundreds of pages of documents obtained by the Milwaukee Journal Sentinel.

Gov. Scott Walker’s administration began to shift its attitude toward the matter last month, when it forced out three guards. The change in approach came 2½ years after the incident — and just before the administration reached an $18.9 million settlement with the inmate, Sydni Briggs.

“The severe suicide attempt by Sydni Briggs in the Copper Lake School on November 9, 2015, was clearly predictable and preventable. It was among a handful of the most egregious juvenile suicide cases that this writer has examined,” reads a report from Lindsay Hayes, who is the director of the National Center on Institutions and Alternatives and has studied more than 3,500 suicide attempts behind bars.

Despite the recent firings, others have been allowed to keep their jobs, including Cassandra Jennings, a prison psychologist who failed to develop a treatment plan for Briggs or assess her when she had harmed herself, according to court documents.

Also staying on at the prison is Deputy Superintendent Lori McAllister, who was promoted to the No. 2 job at the prison seven months after Briggs attempted suicide.

In June 2015, a prison auditor noted staff were not promptly responding to teen inmates’ call lights. McAllister, who at the time was a manager, promised she would train her staff to do that, but didn’t follow through. Five months later, guards did not check on Briggs for 42 minutes, including 23 minutes after she turned on her call light.

McAllister said in a deposition last year that between the time of the prison audit and Briggs’ suicide attempt, she talked to staff about the need to respond to call lights, but did not know if she told them they needed to do so immediately. She said she did not formally train them on the issue and was not sure if her message about responding to call lights got through to her staff.

McAllister wasn’t disciplined at the time for failing to give that training. In June 2016, she was named deputy superintendent, which raised her annual pay from $70,600 to $89,100.

McAllister did not respond to questions sent by email. Department of Corrections spokesman Tristan Cook said McAllister's bosses at the time were aware of the issue with call lights and that it was the responsibility of others to train staff about the need to respond to them.

"Training for (Copper Lake and Lincoln Hills) security staff is the responsibility of security supervisors, not unit managers," Cook said by email.

Cook said the department has made numerous efforts to improve mental health care since Briggs’ suicide attempt, including greatly expanding worker training, hiring a chief psychologist at the prison and appointing a director to oversee and coordinate mental health care for juvenile inmates.

Jennings also was not punished, despite serious questions that were raised about her treatment of Briggs.

At the prison, Briggs was designated as having a serious mental health need and being a suicide risk because she had bipolar disorder, had a history of family suicide and had previously harmed herself.

On Oct. 25, 2015 — two weeks before the suicide attempt — Briggs out of anxiety chewed the inside of her cheek until it bled. Briggs was confined to her room for spitting blood, and Jennings did not treat the incident as a case of self-harm, as she should have, according to Daphne Glindmeyer, a forensic psychiatrist hired as an expert witness by Briggs’ legal team.

“In short, Dr. Jennings took no action whatsoever in response to the October 25, 2015, incident,” Glindmeyer wrote. “This is unacceptable and a gross deviation from the standard of care.”

Glindmeyer noted Jennings never developed a treatment plan for Briggs.

In a separate review, Hayes found that on at least four occasions Jennings did not complete self-harm assessments for Briggs. Jennings and other staff members “often ignored” that Briggs was at risk of harming herself, Hayes wrote.

Cook disputed the findings of the expert reports but did not say why he believed they were wrong. Jennings did not respond to questions sent by email.

'I did a horrible job.'

On the morning of her suicide attempt, Briggs was troubled when she went to her room because another inmate had bullied her and called her a boy, according to guard Darrell Stetzer.

Guards are supposed to check on inmates at least once every 15 minutes and are supposed to respond to them as soon as possible if they activate their call lights. No one checked on Briggs for 42 minutes, including 23 minutes after she turned on her call light — even though little was happening in the living unit at the time.

During that time, guard James Larkin was sitting in front of a computer screen that showed images of Briggs and other inmates in their rooms.

Larkin said in his deposition that he didn’t look at Briggs’s cell during those 42 minutes because he was responsible for watching other inmates. Department of Corrections officials have agreed with that assessment.

Anny Sauvageau, a forensic pathologist hired by Brigg’s legal team, determined that Briggs had likely hanged herself about two minutes before guard Andrew Yorde arrived at her door.

“It is most likely that Sydni would not have hanged herself yet if the guard had responded to her light call in less than 21 minutes,” Sauvageau wrote in a review of the incident.

Working alongside Stetzer, Larkin and Yorde that day were guards Stacey Daigle and Toni Moore Thompson. All five said they did not notice that Briggs’ call light was on for more than 20 minutes — testimony that Hayes called “not plausible.”

Yorde was so close to Briggs’ door at one point that it would have been “virtually impossible” not to see the light, according to Hayes, who reviewed surveillance footage from the incident and visited the living unit. Ten minutes later, Yorde stood “perhaps a dozen steps” from the light, where his view was “clear (and) unobstructed,” she wrote.

When Yorde was asked in July 2017 about filing a report on the incident, he said, “I did a horrible job. I’ll say that right now.”

Months later, in an internal investigation, Yorde acknowledged he saw the light seven minutes before he responded to Briggs' call light. He decided to take out the trash before going to her door, according to records released under the state's open records law.

After Briggs was taken to a hospital, guard Rosemary Esterholm arrived to help monitor the other inmates. She filled out paperwork claiming she had performed five sets of 15-minute checks on inmates at times when she wasn’t in the living unit.

No one from the prison questioned her about that paperwork at the time, she said in a deposition last year.

In September 2017, prison officials made Esterholm a supervisor.

A week before the settlement with Briggs was reached this March, prison officials said Esterholm, Stetzer and Yorde had to go, according interviews and public records. Stetzer resigned and the other two were fired.

Moore Thompson quit soon after Briggs’ suicide attempt, in part because of that incident. Daigle and Larkin continue to work at the prison.

Stetzer, who helped resuscitate Briggs with CPR, noted his bosses cleared him of wrongdoing and praised him for his actions at the time of the incident. Now, he said he feels like a political scapegoat who was forced out to limit the size of Briggs' settlement.

"The fact that I saved her life was not a good thing I guess in their mind," he said Thursday. "I thought the fact that we saved her was important.

"It was, 'You did an awesome job' and then it was, 'You did a terrible thing.' "